Massimo Franchi

Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation

OBJECTIVEnTo assess the efficacy of two laparoscopic methods for the management of endometriomas with regard to pain relief, pregnancy rate, and disease recurrence.nnnDESIGNnProspective, randomized clinical trial.nnnSETTINGnTertiary care hospital.nnnPATIENT(S)nSixty-four patients with advanced stages of endometriosis.nnnINTERVENTION(S)nPatients were randomly allocated at the time of laparoscopy to undergo either cystectomy of the endometrioma (group 1) or drainage of the endometrioma and bipolar coagulation of the inner lining (group 2).nnnMAIN OUTCOME MEASURE(S)nPain relief and pregnancy rate.nnnRESULT(S)nThirty-two patients were enrolled in each group. The 24-month cumulative recurrence rates of dysmenorrhea, deep dyspareunia, and nonmenstrual pelvic pain were lower in group 1 than in group 2 (dysmenorrhea: 15.8% versus 52.9%; deep dyspareunia: 20% versus 75%; nonmenstrual pelvic pain: 10% versus 52.9%). The median interval between the operation and the recurrence of moderate to severe pelvic pain was longer in group 1 than in group 2 (19 months [range, 13.5-24 months] versus 9.5 months [range, 3-20 months]). The 24-month cumulative pregnancy rate was higher in group 1 than in group 2 (66.7% versus 23.5%).nnnCONCLUSION(S)nFor the treatment of ovarian endometriomas, a better outcome with a similar rate of complications is achieved with laparoscopic cystectomy than with drainage and coagulation.

Vaginal extraction of pelvic masses following operative laparoscopy.

Objective: To investigate the clinical outcome of patients undergoing operative laparoscopy for a benign pelvic mass followed by vaginal extraction of the surgical specimen. Methods: Patients presenting with a suspected benign mass greater than 5 cm or an extrauterine pregnancy undergoing operative laparoscopy were considered eligible. Patients with endometriosis, pelvic inflammatory disease, and previous hysterectomy were excluded. In all cases the surgical specimen was removed through a colpotomy performed in laparoscopy at the level of the posterior vaginal fornix. Additionally, a review of the literature has been conducted to specifically address the incidence of colpotomy-related complications. Results: Sixty-three patients were included in the study. The median (range) time required to extract the freed mass to the complete suture of the colpotomy was 15 min (5–31). This time was significantly longer in patients with myomas than for others [median 21 min (range: 10–31) vs median 10 min (5–13), p<0.05]. No intra- and postoperative colpotomy related complications occurred. No patients complained dyspareunia at follow-up visits. A total of 23 studies were reviewed for a total of 501 patients and only one (0.2%) complication (severe vaginal bleeding) was directly attributable to the colpotomy. Conclusion: Removal of a pelvic mass through a laparoscopic colpotomy is feasible, safe, and offers better cosmetic results than transabdominal extraction of the surgical specimen.n

Perinatal outcome of fetuses with a birth weight greater than 4500 g: an analysis of 3356 cases

OBJECTIVEnTo assess the perinatal outcome in a series of macrosomic fetuses according to the intended mode of delivery, and to estimate the individual risk of shoulder dystocia and brachial plexus injury upon information available either prior the onset of labor or at delivery.nnnSTUDY DESIGNnPerinatal and postnatal information of 3356 women who delivered during a 10-year period a macrosomic fetus (>4500 g) in vertex presentation were analyzed. After the exclusion of cases with extraneous factors that may have affected the health of the neonate, patient and neonatal characteristics were compared according to the intended mode of delivery. The contribution of factors known prior labor and at the time of deliver on the occurrence of shoulder dystocia and brachial plexus injury was analyzed using multiple logistic regression analysis.nnnRESULTSnDuring the study period, 2371 women were admitted to spontaneous labor, 778 underwent an induction of labor, and 207 had an elective cesarean section. All cases of shoulder dystocia (n=310), and brachial plexus injury (n=94) occurred among women who delivered vaginally. The rate of brachial plexus injury was higher in cases who had shoulder dystocia than in those who did not (58/310 versus 36/2329, P<0.001). The incidence of brachial plexus injury increases steadily from 0.8 in fetuses weighing 4500-4599 g to 2.86% in those weighing more than 5000 g (P<0.01) and from 2.1 in women taller than 180 cm to 12.5% in those shorter than 155 cm (P<0.05). After adjustment for confounding variables shoulder dystocia (OR 9.2, 95% C.I. 5.38; 15.59), operative vaginal delivery (OR 1.96, 95% C.I. 1.10; 3.49) and clavicular fracture (OR 2.9, 95% C.I. 1.31; 6.44) remained predictors of brachial plexus injury.nnnCONCLUSIONnSince some of these risk factors are known prior to delivery, each woman whose fetus is suspected to weight more than 4500 g should be counseled on her individual risk of severe perinatal morbidity before a decision on the mode of delivery is taken.

Umbilical cord morphology and pregnancy outcome.

Traditionally, the prenatal assessment of the umbilical cord (UC) is limited to the assessment of the number of vessels and to the evaluation of umbilical artery blood flow parameters. Morphologic aspects of the UC have usually been studies by pathologists and retrospectively correlated with the perinatal outcome. The introduction of more sophisticated imaging techniques have offered the possibility to investigate the UC characteristics during fetal life from early to late gestation. A number of investigations have demonstrated that an altered structure of the UC can be associated with pathologic conditions (i.e. Preeclampsia, fetal growth restriction, diabetes, fetal demise). Nomograms of the various UC components have been generated and allow the identification of lean or large umbilical cords, entities frequently associated with fetal growth abnormalities and diabetes. A Whartons jelly reduction has also been invoked as a possible cause of fetal death in the presence of single umbilical artery. Prenatal morphometric UC characteristics as well as arterial and venous blood flow parameters in normal and pathologic conditions will be discussed.

Incisional hernia in gynecologic oncology patients: a 10-year study

Objective To evaluate the independent contribution of clinical and constitutional factors in the development of early and late incisional hernias in women undergoing surgery for uterine cancer. Methods Over 10 years, patients undergoing extended abdominal hysterectomy for cervical or endometrial malignancies through a vertical incision were followed for the identification of incisional hernias. Logistic regression and survival analyses were used for statistics. Results Four hundred fifty-five women were included in the study, 77 of whom (16.9%) developed incisional hernias. The median (range) body mass index was higher in women who developed an incisional hernia than in those who did not (28 [19–44] kg/m2 versus 24 [16–41] kg/m2; P < .01). The frequencies of diabetes (14.3% versus 4.8%; P < .01), wound sepsis (10.4% versus 1.3%; P < .05), and fascial closure with interrupted sutures (70.1% versus 55.6%; P < .05) were significantly higher in women with incisional hernia than in those without. Multiple logistic regression revealed that, after adjustment for confounding variables, the only factors associated with incisional hernia formation within 1 year from the operation were body mass index above 27 kg/m2 (odds ratio [OR] 3.68; 95% confidence interval [CI] 1.38, 9.81; P < .01) and wound infection (OR 5.05; 95% CI 1.39, 18.37; P < .01), whereas the factors associated with incisional hernia formation at least 3 years after surgery were diabetes (OR 6.68; 95% CI 2.02, 22; P < .01) and wound infection (OR 8.55; 95% CI 1.54, 47.5; P < .01). For hernia developing after 5 years (OR 8.32; 95% CI 1.41, 55.65; P < .05) and 8 years (OR 49.52; 95% CI 2.72, 907.14; P < .01), the only significant association was found with diabetes. Conclusion Late incisional hernia formation does not depend on conditions present at the time of operation or on surgical technique. Other factors such as diabetes seem to play an important role in the development of late incisional hernia.

Conservative treatment by chemotherapy and uterine arteries embolization of a cesarean scar pregnancy.

We report a case of a viable cesarean scar pregnancy diagnosed at 7 weeks of gestation. The patient was conservatively managed by chemotherapy, intra-amniotic instillation of potassium chloride, and bilateral uterine artery embolization. The gestational sac was not sonographically visible 44 days after the treatment. No surgical treatment was necessary.

A multicentre collaborative study on the use of cold scalpel and electrocautery for midline abdominal incision.

BACKGROUNDnAlthough studies in animals demonstrated a better wound healing after abdominal incision with cold scalpel than with electrocautery, clinical experiences did not confirm these findings. The purpose of this study was to compare early and late wound complications between diathermy and scalpel in gynecologic oncologic patients undergoing midline abdominal incision.nnnMETHODSnPatients undergoing midline abdominal incision for uterine malignancies were divided into two groups according to the method used to perform the abdominal midline incision: cold scalpel and diathermy in coagulation mode. Early and late complications were compared. Logistic regressions were used for statistical analysis.nnnRESULTSnNine hundred sixty-four patients were included, of whom 531 were in the scalpel group and 433 in the electrocautery group. Both groups were similar with respect to demographic, operative, and postoperative characteristics. Univariate analysis revealed a higher incidence of severe wound complications in the scalpel group than in the electrocautery group (8 of 531 versus 1 of 433, P <0.05). After adjustment for confounding variables (eg, age, body mass index) no differences were found between groups.nnnCONCLUSIONSnScalpel and diathermy are similar in terms of early and late wound complications when used to perform midline abdominal incisions. Therefore the choice of which method to use remains only a matter of surgeon preference.

Longitudinal umbilical vein blood flow changes in normal and growth-retarded fetuses

Objective.u2003 To explore whether the umbilical vein blood flow of growth‐retarded fetuses with normal Doppler parameters changes over time differently to that of normally grown fetuses.

Recurrence of ovarian endometriosis and anatomical location of the primary lesion

OBJECTIVEnTo investigate whether the risk of endometriosis recurrence and pregnancy rate are related to the side of the pelvis on which the primary lesion is found.nnnDESIGNnCross-sectional study.nnnSETTINGnTertiary institutional hospital.nnnPATIENT(S)nOne hundred and twenty-one patients with advanced-stage pelvic endometriosis.nnnINTERVENTION(S)nConservative laparoscopic treatment.nnnMAIN OUTCOME MEASURE(S)nEndometriosis recurrence and pregnancy rate.nnnRESULT(S)nEndometriosis was localized on the left hemipelvis, right hemipelvis, and bilaterally in 47.9%, 33.9%, and 18.2% of patients, respectively. The overall rate of disease recurrence was 17.3%. The recurrence rate was higher when the left ovary was involved than when it was not (29% vs. 7.3%; P<.05). The overall rate of spontaneous pregnancy was 48.1%. The median interval between surgery and occurrence of pregnancy was shorter in patients with endometriosis limited to the right hemipelvis than in those with disease limited to the left side (21 months [range, 12-48 months] vs. 9 months [range, 6-12 months]; P<.01).nnnCONCLUSION(S)nThe likelihood of disease recurrence is lower when endometriosis is located only on the right side of the pelvis than when the left side is involved. In patients who try to conceive, the time between surgery and occurrence of pregnancy seems to be shorter when the endometriosis is localized in the right hemipelvis.

Bioelectrical impedance analysis during pregnancy and neonatal birth weight

OBJECTIVEnTo generate reference ranges for bioelectrical impedance indices throughout pregnancy and to investigate whether a relationship exists between these indices and the neonatal birth weight.nnnSTUDY DESIGNnPregnant women with a singleton gestation, gestational age lower than 12 weeks, and absence of medical diseases before pregnancy were enrolled. Patients with pregnancy complications, such as hypertensive disorders, diabetes, and antiphospholipides syndrome were excluded. Antrophometric maternal parameters and bioelectrical impedance measurements were performed during the first, second, third trimester of pregnancy, at delivery and 60 days after delivery. Height(2)/resistance (cm(2)/Omega) and height(2)/reactance (cm(2)/Omega) were utilized to estimate the total and extracellular body water amounts, respectively. Spearman rank correlations and cox proportional hazard modelling were used for statistical purposes.nnnRESULTSn169 patients completed all measurements. Total and extracellular water amounts significantly increase as pregnancy advances and return to the pre-pregnancy values within 60 days after delivery. After adjustment for gestational age at delivery, fetal sex, and smoking habits, height(2)/resistance at 25 weeks (hazard=1.04, 95% confidence interval (CI) 1.02-1.06, P<0.005), height(2)/resistance at 30 weeks (hazard=1.03, 95% CI 1.01-1.05, P<0.005), height(2)/reactance at 20 weeks (hazard=1.03,95% CI 1.01-1.05, P<0.005), and height(2)/reactance at 25 weeks (hazard=1.03, 95% CI 1.01-1.04, P<0.01) were found to be independent predictors of birth weight.nnnCONCLUSIONnWe have provided reference ranges for bioimpedance analysis during pregnancy, an easy, fast and non invasive method to estimate the body water composition during pregnancy. Bioelectrical impedance indices during the second trimester of pregnancy are independently related to the birth weight.